Leadership in the context of digital health services: A concept analysis

Abstract Aim To define and clarify the concept of leadership in the context of digital health services using Walker's and Avant's concept analysis model. Background Conceptualizing leadership in the context of digital health services is needed to deliver higher quality services and advance research. Method Searches were conducted of MEDLINE (Ovid), Scopus, CINAHL (EBSCO) and ProQuest (ABI/INFORM). Empirical articles were included if they reported attributes, antecedents or consequences of leadership in the study context. A total of 4037 references were identified; 23 were included. Results Leadership attributes concerned leaders' behaviour, roles and qualities. Antecedents concerned informatics skills and competence, information and tools, understanding care systems and their complexity and education. Consequences related to organization, professionals and patient and care. Conclusion Based on our results, the term ‘e‐leadership’ should be more widely utilized in nursing practice and research. Implications for nursing management Nurse leaders need to be strong leaders; they need to be visionary and use strategic thinking to develop existing and new digital solutions. By becoming e‐leaders, nurse leaders may increase the successful development and implementation of eHealth and benefit clinicians and patients.


| INTRODUCTION
Digital health care is important because its meaningfulness has often been emphasized due to problems in modern health care, such as increasing costs (De La Torre-Diéz et al., 2015) and COVID-19 (Wind et al., 2020). For example, hospitals with electronic health records (EHRs) with basic capabilities (EHRs) have a 12% lower average cost than those hospitals that do not have EHR (Highfill, 2019). However, despite their potential and heavy investment, implementation of digital health services often fails (Herrmann et al., 2018;Öberg et al., 2018), with poor leadership cited as one reason (Abbott et al., 2014;Mair et al., 2012); leaders often seem ill-prepared to handle future challenges (Day, 2000), and it may be that leaders are not conscious of what leadership actually is in the context of digital health services.
Although health care leaders traditionally lead clinical health services (Sood et al., 2017), leadership develops over time and in different contexts (Day, 2000). Recently, health care leadership has been transformed by digital services; nurse leaders' responsibilities have expanded into digitalizing health care (Cowan, 2014;Sandström et al., 2011) and even artificial intelligence (Chen & Decary, 2020). As Cowan (2014) noted, nurse leaders have more commonly been tasked with coordinating digital health care, and their role seems to be more emphasized in leading digital health services than physician leaders (Keijser et al., 2016). According to Strudwick, Nagle, Morgan, et al. (2019), leaders were likely unaware of the gaps they have in their informatics knowledge and skills. In addition, the literature provides little clarity as to what leadership in the context of digital health services entails (Lulu, 2019;Tremblay, 2017), and it has been suggested that research should focus on continuously transforming leadership (Dickson, 2009). Because of the lack of clarity about leadership in digital health services, Walker and Avant's (2019) method of concept analysis was used to identify the attributes, antecedents, consequences and empirical referents of this concept. Understanding the concept of leadership in the context of digital health services would be important, since it may ease leaders to obtain required competencies and behaviours related to information and communication technology (ICT) acquisition and use (Strudwick, Nagle, Morgan, et al., 2019).

| BACKGROUND
Health care organizations have been recognized as complex (Begun & Thygeson, 2015): they have been scrutinized as complex adaptive systems (CASs) that can self-organize, adapt and learn (Paina & Peters, 2012). Digitalization transforms the context in which leaders operate (Hernez-Broome & Hughes, 2004). High levels of digitalization tend to make health care organizations even more challenging to lead: every new digital service requires decision-making, implementation, assessment and secure usage among end-users. Avolio et al. (2014) have suggested that organizational structures, including leadership, may transform due to the implementation of Advanced Information Technology (AIT). Thus, every digital health solution may be understood as a complex innovation, which according to Chuang et al. (2012) means that the implementation process requires systematic organizational changes in structure, staffing, workflows, and/or policies, as well as coordinated innovation use by multiple organizational membersall of which concern leaders. Digital innovations then again may transform the work of professionals and enable virtual or geographically dispersed units and teams (Hernez-Broome & Hughes, 2004). The interdisciplinary literature shows that leadership in digital environment requires different kinds of leadership behaviours such as transformational behaviour, strategic-oriented behaviour and servant leadership (Avolio et al., 2014;Larjovuori et al., 2016).
Successful implementation of digital services would be important since their costs are extremely high. For example, in the United Kingdom EHR implementation costs £200 million (EUR 275 million, USD 293 million), and in Denmark DKK 2.8 billion (EUR 375 million, USD 400 million). The implementation of the new EHR has not been trouble-free in the United Kingdom or Denmark, and in Norway, managers have been recognized to play an important part in the implementation process (Hertzum & Ellingsen, 2019). According to a scoping review by Laukka et al. (2020), health care leaders need to adopt certain behaviours to support the implementation of health information technology; leaders need to act as supporters, change managers, advocates, project managers, decision-makers, facilitators and champions. Another review shows that leaders also need several informatics competencies such as informatics knowledge, informatics skills and computer skills (Strudwick, Nagle, Kassam, et al., 2019).
However, leaders cannot fully act in expected roles since their understanding of digitalization and its implementation may not be any better than their subordinates' understanding of it (Laukka et al., 2020). This may be because there is a lack of understanding about leadership in the context of digital health services, and thus, health care leaders may be ill-prepared to lead in a transformed digital environment. As it appears, prior reviews synthesized leadership roles and competencies but making the most of HIT requires proper health care leadership in other processes as well (Simpson, 2004).
For a health care leader managing technology is an issue about the three 'Ps': People, processes and (computer) programmes (Simpson, 2004).
Previous concept analyses have scrutinized health care leadership, for example, in terms of implementation leadership (Castiglione, 2020), transformational leadership (Fischer, 2016) and succession planning (Titzer & Shirey, 2013). Since research on leadership in this context is limited and developing transforming leadership is currently challenged by rapid digital innovation (Dickson, 2009), conceptualizing leadership may provide guidance for service development and future research. The conceptualization of leadership in the context of digital health services provides a better understanding of today's health care leadership and how it supports digitalization and improves implementation. In addition, conceptualization may facilitate further research and thus help reshape existing and emerging leadership models. Precise conceptualization of leadership in the context of digital health services is therefore needed to support leaders working on the frontline and at middle and senior management levels, to improve digital health services, facilitate evolving leadership and advance research. Thus, the aim of this paper was to define and clarify the concept of leadership in the context of digital health services using Walker's and Avant's concept analysis model.

| METHODS
The detailed protocol for this concept analysis has been published (Laukka et al., 2021). We used the concept analysis model by Walker and Avant (2019), a frequently used tool in health care settings (Nuopponen, 2010). To identify all relevant literature about leadership in the context of digital health services, a literature review was conducted in accordance with the Joanna Briggs Institute's (JBI) search protocol for scoping reviews .

| Eligibility criteria
A participants, concept and context (PCC) framework was applied when defining eligibility criteria (Table 1).
Peer-reviewed empirical studies were considered. The study participants comprised all positional health care leaders; we included nursing and physician leaders, since one may safely generalize about leadership in the context of digital health services (Keijser et al., 2016). Publications eligible for inclusion must either define or clarify the concept of leadership in the relevant context.

| Search strategy
A three-step search strategy was used to retrieve both published and unpublished studies. An information specialist helped develop the initial and final search strategies. An initial limited search of MEDLINE (Ovid) was undertaken on 19 October 2020 as part of a concept analysis protocol (Laukka et al., 2021). On 31 November 2020, four databases (MEDLINE (Ovid), Scopus, CINAHL (EBSCO) and ProQuest (ABI/INFORM)) were searched using indexing and keywords with a limit of 10 years (Appendix S1). Keywords were truncated where appropriate.
Searching returned 4037 possible records. After removing 1176 duplicates, 2861 records underwent title and abstract screening, which included 2558 papers that did not meet the inclusion criteria.
Full-text assessment for eligibility was performed on 303 papers, of which 23 met the inclusion criteria ( Figure 1).

| Attributes, antecedents, consequences and empirical referents
According to Walker and Avant (2019), the defining attributes of a concept are the heart of a concept analysis. We defined the key attributes of leadership in the study context and generated them as clusters. We also identified antecedents and consequences-events that occur before or because of leadership in the context of digital health services ( Figure 2).

| Attributes
The defining attributes associated with leadership in the study context were identified and categorized as behaviours, roles and qualities ( Figure 3).

Leadership as a set of behaviours
The following nine attributes concerned leadership behaviour: acting as a strong and effective leader; visionary and innovative behaviour; supportive behaviour; strategic-oriented behaviour; IT-oriented behaviour; transformational and change-oriented behaviour; knowledge-oriented behaviour; responsible behaviour; and competence-orientated behaviour.
According to earlier studies (Ahonen et al., 2016;Avdagovska et al., 2020;Gjellebaek et al., 2020;Kahn et al., 2019;Kujala, Heponiemi, & Hilama, 2019;Simon et al., 2013), leaders in the study context had to act as strong, effective leaders, meaning, for example, that they had to stand behind the implementation of digital health services. Visionary and innovative behaviour (

Leadership as a set of roles
Seven attributes encapsulated leadership roles: resource allocator; decision-maker; developer; informer; advocate; collaborator; and facilitator. Ahonen et al. (2016) suggested that leaders are responsible for allocating resources when implementing and using digital services.
According to Strudwick, Booth, Bjarnadottir, et al. (2019) leaders also act as decision-makers and select technologies to be implemented.
The included paper also suggested that as informers and communicators, leaders share information in an organization (Kujala, (Strudwick, Nagle, Morgan, et al., 2019). For example, leaders must stand behind the implemented digital health system, but they also need to advocate for personnel and patients when implementing or developing digital health solutions (Strudwick, Booth, Bjarnadottir, et al., 2019).

Leadership as a set of qualities
Three particular leadership qualities were emphasized in earlier studies: commitment and engagement (Ahonen et al., 2016;Amlung et al., 2020;Andreassen et al., 2015;Mills et al., 2010;Simpson, 2013); being active (Kolltveit et al., 2017) and authoritativeness (Chen, 2018). According to Kolltveit et al. (2017) leaders' commitment and engagement seem to be especially important: for example, there seems to be a definite need for a leader to support unequivocally the conditions that support digitalization. Among other things, leader's authoritativeness is relevant to a eHealth project's success (Chen, 2018).

| Antecedents
Four antecedents must exist before leadership in digital services can occur ( Figure 2): digital health services must already exist or be on the point of introduction if leaders are to lead in this respect.
Finally, according to Gjellebaek et al. (2020) and Sharpp et al. (2019) leaders need to have sufficient education to lead digital health services.

| Consequences
Leadership in the context of digital health services exhibited characteristics desirable for health care organizations, professionals and patients and their care (Figure 2). Earlier studies show that from an

T A B L E 3 Closely related terms and their definitions
Closely related term The used definition e-leadership 'E-leadership is defined as a social influence process mediated by AIT to produce a change in attitudes, feelings, thinking, behavior, and/or performance with individuals, groups, and/or organizations'. (Avolio et al., 2000, p 617).
Virtual leadership 'When an individual manages a group they do not see in person, lead a team that is dispersed geographically, or work within a team that is partially remote, they are part of the virtual workplace'. (Dinnocenzo, 2006, p. 14) organizational perspective, good leadership seemed to increase the successful implementation and innovativeness of digital solutions  (Chen, 2018;Liebe et al., 2016;Mills et al., 2010). When leadership in the context of digital health services is successful, it also makes organizations more resilient, allowing them to achieve goals and gain the full benefits of technology (Kujala, Hörhammer, et al., 2019;Mills et al., 2010). Due to the leadership in our context, organizations may also achieve better financial performance (Mills et al., 2010) and greater level of sustainability (Strudwick, Booth, Bjarnadottir, et al., 2019).

| Model case, borderline and contrary cases
We developed one model case to represent a real-life example of leadership using the defining attributes discussed earlier. We also represented borderline and contrary cases (Table 4).

| Empirical referents
Empirical referents are measurable ways to demonstrate the occurrence of leadership in the study context. However, there exists no validated metrics to measure this complex phenomenon; instead, there is a metric that measures parts of it, namely, Nursing Informatics Competency Assessment for Nurse Leaders (Collins et al., 2017).

| LIMITATIONS
This concept analysis has several limitations. Data extraction was completed by one researcher (although it was discussed in the research group). Few papers provided an implicit definition for leadership in the context of digital health services, and these definitions were context-specific. The papers were conducted in affluent countries with high levels of digitalization; thus, the results might not be transferable to lower income countries. In addition, the database searchers had a limit of 10 years, which might have excluded some potential articles. Organization C has not defined any strategy regarding eHealth, although it is aware that it has been part of the national programme for several years. However, they some must-have IT solutions, such as EHRs, have been implemented, but the nurse executive C among other leaders acquiesced in the decision-making with others. IT management selected the EHR to be implemented, which was ratified by top management. No employees or frontline leaders participated in EHR selection.
Nurse executive C who was responsible for the implementation, did not take any training concerning the implementing solution. Implementation has been made rapidly and with insufficient resources. Training of the employees has happened at work. Nurse executive C is not very familiar with IT, politics related to it, or any risks that may be associated with it. She/he simply prefers to use e-mail and leave everything else regarding technology to the IT department. IT decisions tend to fail to meet clinical practice needs. Nurse executive C has not discarded traditional models of bureaucratic leadership.
When implementing new digital health services, organization A has provided IT and software training for health care leaders in all leadership positions from top managers to frontline leaders, and nurse executive A has been attending to those (competence oriented). Due to the training, she/he has become skilled with informatics, and her/his skills are regularly evaluated by organization and herself/himself. She/he is familiar with fundamentals or IT, and she/he takes care that also other leaders at all levels are familiar with the fundamentals of IT, can analyse big data and use it for strategic decision-making in an ethical way (IT-oriented).
Leaders are trained to be critical towards the data that they receive from the decision-support tools--they evaluate the data (knowledge-oriented).
Nurse executive A together with top managers has agreed that having informatics-savvy staff is one strategic goal of organization A. Nurse executive A has encouraged and supported frontline leaders have arrange IT training for staff and regularly evaluate their IT skills (supportive behaviour).
She/he has also instructed frontline leaders to identify those professionals who either struggle with IT or are enthusiastic about it. For the first group they offer more support and training, while the professionals belonging to the latter group are identified as 'champions'.
Nurse executive A has adopted transformational and changeoriented behaviour; she/he understands that implementation and usage of digital health services requires resources; enough resources are thus provided for IT projects (resource Nurse executive A utilizes social media for leadership and development purposes. When using social media, leaders are not bound to geographic locations or time zones, and they may even collaborate internationally (being active).

| CONCLUSIONS
Our concept analysis creates a foundation for further research with its robust definition for leadership in digital health services. We encourage redefining and developing the term e-leadership within the field. The constantly shifting context will doubtless influence leadership and leaders' behaviour. The increasing role of artificial intelligence may alter leadership in health care in the coming years-indeed, understanding leadership in the era of AI is surely a subject ripe for future study. To conclude, we urge use of the term e-leadership in nursing research and in practice.

| IMPLICATIONS FOR NURSING MANAGEMENT
The literature lacks a comprehensive understanding of leadership in the context of digital health services. Based on the results of our analysis, we created an initial framework of leadership, which may also be utilized when studying nursing leadership. As leadership, also nursing leadership develops over time and in different contexts. During the past decade, the rapid digitalization of health care has transformed nursing leadership.
Based on the results, there exist several different concepts through which leadership in our context may be defined. One of the most promising of these is the e-leadership presented by Avolio et al. (2000); according to them, e-leadership has been described as a Second, the analysis reveals that leaders who are fully engaged in the context of digital health services seem to improve the implementation of those services; they release potential benefits or consequences to an organization. As stated earlier, digital health services implementation often fails (Herrmann et al., 2018;Öberg et al., 2018), and poor leadership might be one reason for that (Abbott et al., 2014;Mair et al., 2012). It might be that health care leaders, including nursing leaders, are ill-prepared to handle digitalization; however, if they are fully engaged it seems-based on this work-that they might be more successful. This responsibility seems to fall especially on nurse leaders (Cowan, 2014), who based on our results work in an important role in a workgroup consisting of several different stakeholders (e.g., IT management, staff, IT vendors and patients). Strudwick, Nagle, Kassam, et al. (2019) noted that leaders have to be more savvy with regard to IT. We recommend educating nurse leaders to become e-leaders who adopt the necessary behaviours and roles and emphasize certain qualities when leading digital health services. Nurse leaders need to be visionary and use strategic thinking to develop existing and new digital solutions. Nurse leaders also need to listen to clinicians, evaluate their digital competence and provide support for frequent IT-related changes. Nurse leaders need to advocate for clinicians and patients when developing digital health solutions. By becoming such e-leaders, nurse leaders may increase the successful development and implementation of eHealth and benefit clinicians and patients.